Basic Information
| Provider Information | |||||||||
| NPI: | 1720364367 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONOFAOS | ||||||||
| FirstName: | PETROS | ||||||||
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| Credential: | M.D., PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1407 UNION AVE | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018668525 | ||||||||
| FaxNumber: | 9013022525 | ||||||||
| Practice Location | |||||||||
| Address1: | 1068 CRESTHAVEN RD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381190800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018668525 | ||||||||
| FaxNumber: | 9013022525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2011 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | MD50989 | TN | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1720364367 | 05 | MO | MEDICAID | 177445 | 05 | AL | MEDICAID | 003180136A | 05 | GA | MEDICAID | 08231501 | 05 | MS | MEDICAID | Q007443 | 05 | TN | MEDICAID | 204025001 | 05 | AR | MEDICAID |